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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 35. -3 -1 BOX 15 I I r - a . -1 "r m I I 1 1 rr .,6 i �ti , qL , ' 66 . kOj I wr fta 3111 IN an 01671 b PUTNAM COUNTY DEPARTMENT OF HEALTH ...._..SQ......?. -.MENTAL . _........_ ....: ALTSRV OF V�RQ , CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT #1k1 Located at 49 F% `, 10 WPW t O No Town or Village Subdivision name Subd. Lot # " Date Subdivision Approved Owner /Applicant Name "(ND-F-W o? . yo HaH Mailing Address '7U f-A-, TD M4ZT- Amount of Fee Enclosed 4 1 �xj oo Building Type Lot Area U + No. of I Tax Map %a Block �) Lot Renewal Revision _ n Date of Previous Approval �1 1 9 3edrooms 4 Design.Flow GPD $00 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of �2 0 gallon septic tank and Other Requirements: To be constructed by TBb Address Public Supply From Address or, �_ Private Supply Drilled by -..- _.TbD ..__.___�....�.... Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the anuate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: Address P.E. R.A. Date 00 Q4- License # 604 APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Approved for discharge ' of domestic sanitary sewage only. By: Title: '00 r1l S Date: 5 h?-ttotf White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH 14 ^ DIVISION OF ENVIRONMENTAL HEALTH SERVICES -/'0J -.0 Y APPLICATION TO CONST.RU.CT. A "7t ER ALL; :..::._ ..... -_ - please print or type PCHD Permit # Q / Well Location: Street Address: Town/Village L Tax Grid # f A" TO ft "� l y • ? jOO Map M5, Block 4) Lot(s) Well Owner: Name: NNW& - JX WAK Address: I 4-so `Vo MWQ . P09-30J r I m Use of Well: Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought '5+- gpm # People Served 4 of Daily Usage O_gal. Reason for Replace Existing Supply Test/Observation Additional Supply DrEEng New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes No Name of subdivision —' Lot No. Water Well Contractor: Address: Is Public Water Supply available to site? .................................. ............................... Yes No _ Name of Public Water Supply: Town/Village ' Distance to property from nearest water main: `_ Proposed well location & sources of contaminatio to be provided on separat bee plan. Date: _Q _ WA-.-'_ Applicant Signature:.--r V PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED .FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam County. Date of Issue ��'� �.f 7' Permit Issuing Official: Date of Expiration Title: Pl-hS Permit is Non- Transferrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 r- PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO ABANDON A WATER WELL please print or type PCHD PERMIT # Well Location: Street Address: TownNillage Tax Grid # �D �- TO M*tf _ ", pl��Sed Map? Block � Lot(s) Well Owner: Name: J Address: Well Type: X Drilled Driven Dug Gravel Other Depth Data: Well Depth ft Static Water Level ft Date Measured Use of Well: Residential Public Supply Air /Cond/Heat Pump Abandoned 1- primary Business Farm Test/Observation Other (specify) 2- secondary Industrial Institutional Standby Water Well Contractor: Name: n Address: �E) Reason For Abandonment: Description of Work To Be Performed: ftk_Tlo TO VA NE�i CtMew Date: �+ `� Applicant Signature: u PERMIT This permit, to abandon one water well as set, forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code, Subpart 5 -2 of Part 5 of the New York State Sanitary Code and/or Part 75 of 10 NYCRR and provided that: Within 30 days of the completion of the abandonment of the water well, the applicant shall submit to the Department a certified statement that the information delineated on the application for this permit has been completed. 5-11— O T Date of Issue Permit Issuing Official e#—S Title White copy: HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WA -97 DIMHSION Off" E '1RONMErNI& M HEALTH CO VIt"'ES uzx'IITffFICATE OF CONS TRuCTRUN CUMPLIAI h F ®IS DhWA r, 'ICIRMA'A IVAMI'M A SYSTEIbI PCHD CONSTRUCTION PERMIT # V4 -41- 04 A -M IA'' Located at -4ern �+IPA T D M940 PON Town or Village Owner /Applicant Name XWU\O''r N W -KO-A Formerly ?w5H Tax Map '45' Block '� Subdivision Name ° Subd. Lot # Lot I Mailing Address /t?p F44A i 0 H4W PNP PAIM -600 Zip 1 1, Date Construction Permit Issued by PCHD Separate Seweraim System built by CO-L1 C4 C-W P(:V 4� Address P46 ° n- r `O - Consisting of '6-50 Gallon Septic Tank and U -1 W i Other Requirements: Water Suu) Public Supply From Address ®r: .A Private Supply Drilled by f �,Q�II� �� �' Address '` I��CSz P05 4 Building Type ' Il �� t•- Has erosion control been completed ?� Number of Bedrooms A- Has garbage grinder been installed? ho I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulation , of the Putnam County art ent of Health. Date: L4 ®� Certified by v P.E.:X R.A. (Desi Pro�ession�i Address 1p5o K ��. �� , 1 1 � j �� License # %0141 Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are subject to modification or change when, in the judgment of the Public Health Director, such revocation, modification or ch ge is necessary. By; Title: 11'2 Date: 71C. to White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Dear Mr. Nichols: September 6, 2006 ROBERT I BONDI County Executive :.. ROBERT MORRIS, PE':., Director of Environmental Health Re: Field Inspection- Hinton Farm to Market Road (T)Patterson, TM #35. -3 -1 A re- inspection at the above referenced lot has been completed. There are no further comments to be addressed. If you have any further questions, please contact me at (845) 278 -6130; ext. 2261. _._ .._.._. ,.._ _...._ .. -. -_. _-_ -.... , - _. ._ ..._.. ,. , Sincerely, GDR:Im Gene D. Reed Sr. Environmental Engineering Aide Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225- 5186::Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648 August 31, 2006 Putnam County Health Department .1 Geneva Road Brewster, New York 10509 Tarry W. Nichols Jr., P.E. Patterson Park - Suite 106 2050 Route 22 Brewster, NY 10509 Email: hnengineer @aol.com RE: Individual SSTS Compliance (Addition) - Hinton 480 Farm To Market Road Patterson, NY T.M. # 35. -3 -1 Dear Mr. Budzinski: Enclosed are the following: 1. Five (5) prints of Drawing S -1, "As -Built SSTS ", dated 04/11/06. 2. "Certificate of Construction Compliance for Sewage Treatment System ", 3. Three (3) copies of "Guarantee of Subsurface Treatment System ", dated 04/21/06. 4. Laboratory Report dated 04/04/05. 5. "Well Completion Report", dated 03/28/05. 6. Application Fee in the amount of $300.00 payable to Putnam County Health Dept. 7. "Well Abandonment Report", dated 08/31/06. If there are any questions concerning the enclosed, please call. Very truly yours, 9 Harry W. hols Jr., P.E. HWN:gav 03- 086.00 PUTNAM COUNTY DEPARTMENT OF HEAL' DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE'PREATKM SYSTEM /V /o er or Purchaser of Building Jo; Wig o Building Constructed by Aga Location - Street Tax Map Block Lot 0 Town/Village r - Subdivision Name Building Type Subdivision Lot # I represent that I am wholly and .completely responsible for the location, workmanship, material, construction and drainage of the sewage treatment system serving the above - described property, and that is has been constricted as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations ofthe Putnam County Department of Health, and hereby guarantee to the owner, his successors, hens or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage treatment system, or any repairs made by me 'to such system, except where the failure to operate properly is caused by the willful or negligent act of the occupant of the building utilizing the system. ..... .. .. ..... . The undcrsigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County Department of Health as to whether or not the failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. Dated- Month Day L Year Z006 Signature: 440�_� per, General Contractor (Owner) - Signature Corporation Name (if corporation) Address: State jJ `'� Zip �A Title: cGE:oi✓ je Corporation Name (if corpo�� ) Address: 0 T`,C/C_ State Zip Form G5 -97 PUTNAM COUNTY DEPART'MEN'T' OF HEALTH DMSION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM 0 r or Purchaser of Building, JOf X000 Building Constructed by 4d,o f P,�m; o f'N*W ?pn Location - Street 1S-1 i Tax Map Block Lot PA-f t, r 0 � - TownNillage Subdivision Name Building Type Subdivision Lot # I represent that 1 am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage treatment system serving the above- described property, and that is has been constructed as shown on the 'approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage treatment system, or any repairs made by me to such system, except where the failure to operate properly is caused by the willful or negligent act of the occupant of the building utilizing the system. The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County Department of Health as to whether or not the failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. Dated: Month Day 31 Year 2,0y,4-' General Contractor (Owner) - Signature C .7/. -/-1 Ciy a Is/ , — Corporation Name (if corporation) Address: `k 5 U NVA `y'l141 `� State tJJ Zip Si ature: 6:;, Title: �i r�s7��J� Corporation Name (if corporation) Address: 3re4+� -� State /4/- Y Zip �0j o i Form GS -97 PUTNAM COUNTY DEPARTMENT OF HEALTH (DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner Purchaser of Buildinv Tax Map Block Lot Building Constructed by AA 0 FA-W AL� E "I Location - Street TownNillage Subdivision Name Building Type Subdivision Lot # I represent that I am wholly and completely responsible for the location, workmanship,. material, construction and drainage of the sewage treatment system serving the above- described property, and that is has been constructed as shown on the'approved plan or approved:.amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for .a period of two years immediately following the date of approval of the "Certificate of Construction. Compliance" for the sewage treatment system, or any repairs made by me to such system, except where the failure to operate properly is caused by the willful or negligent act of the occupant of the building utilizing the _ . system: _ The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County Department of Health as to;.whether or not the failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. Dated: Month 03 Da ` y 31 Year ��� Signature.: '/ . ? - (;�?es Title: General Contractor (Owner) Signature C�q aj Corporation Name (if corporation) Address: 1lj,�Ql �Waj -- State j Zip O�o� Corporation Name (if corporation) Address:�e.� State Zip Form GS -97 JEOWATER, SOIL AND AIR ANALYSIS ffl#�E� 41 Kenosia Avenue -I Danbury +Connecticut 06810. 1 Telephone 203 -79$- 2229.. w.�... _ Ow. _- _ _......y.. _ - .ww_ a4 ..< Luc i- . ww vI' �• w -..a n_. s -.L....rz .a2u., f• . ..+V .•1- -_c..rweL rr Mailing Information: Collector's Information: Tame: PF Beal & Sons Client: Hinton Name: Kevin Bentson Address: 4 Putnam Ave Address of site: Farm to Market Road City: Brewster City: Brewster State: NY Zip: 10509 State: N.Y. Zip: Telephone: 845-279-2460 Fax: 845-279-6613 Telephone: Sample's Information,: Site: Date Collected: 4/1/05 Date Received: 4/2/05 Preservative: N/A Time Collected: 3:00pm Time Received: 12:00pm Temperature: <4C Lab No.:. J0602716 Date Analyzed Test Name Result MCL Method 4/2/2005 13:00 Total Coliform 4/2/2005 Chlorine Free Residual 4/2/2005 Color 4/2/2005 Odor 4/5/2005 Iron 4/5/2005 Manganese 4/5/2005 Sodium 4/4/2005 Chloride 4/4/2005 Hardness 4/4/2005 Nitrate 4/4/05 10:00 Nitrite -,-.a /2105... x- 4/4/05 Sulfate 4/2/05 Turbidity 4/4/05 Lead 4/4/05 Alkalinity Absent Absent SMWW 9222B <0.1 mg /L N/A SMWW 4500CIG ND 15 Units SMWW 2120 B ND 3 TONs SMWW 2150 B <0.050 mg /L 0.3 mg /L SMWW 3111 B <0.050 mg /L 0.3 mg /L SMWW 3111 B 9.05 mg /L N/A SMWW 3111 B 4 mg /L 250 mg /L SMWW 4500 CI C 48 mg /L N/A SMWW 2340 C <0.1 mg /L 10 mg /L SMWW 4500 NO3E <0.1 mg /L 1,0 mg /L SMWW 4500.NO3E. - *5.17 S.U:F -- �-6:5y85•S:�-. __.._,._..�:-- •-- SI'��500-H•�.� �. ..._;.- _.. -,... 10.17 mg /L 250 mg /L SMWW 4500 SO4F 0.36 NTU 5 NTUs SMWW 2130 B <1.0 ug /L 15 ug /L SMWW 3113 B 20 mg /L N/A SMWW 2320 B COMMENTS: *BELOW MCL At the time of analysis the sample was acceptable for total coliform N/A = Not Applicable S.U.= Standard Unit MCL- Max. Contaminant Level ug /L- micrograms per Liter Signature: Michael Lapman President mg /L- milligrams per Liter ND- None Detected NTU- Nephelometric Turbidity Unit TON- Threshold Odor Number Reviewed by: Sharon Houlahan, Director State #: PH -0218 ELAP #: 11715 CONNECTICUT, NEW YORK AND NELAC CERTIFIED Toll Free 866 -JMS -5097 I Corporate Fax 203 - 798 -2408 1 Lab Fax 203 - 798 -2107 1 www.jmsenvironmental.com JMS Environmental Services, Inc, qq � LZ WATER, SOIL AND AIR ANALYSIS Mailing Information: Name: PF Beal & Sons Address: 4 Putnam Ave City: Brewster State: NY Telephone: 845 - 279 -2460 Sample's Information: Client: Hinton Zip: 10509 Fax: 845 - 279 -6613 41 Kenosia Avenue I Danbury, Connecticut 06810 1 Telephone 203 - 798 -2229 Collector's Information: Name: Kevin Address of site: Farm to Market City: Brewster State: N.Y. Zip: Telephone: Site: Slop Sink Date Collected: 2/23/05 Date Received: 2/25/05 Preservative: N/A Time Collected: 11:15am Time Received: 1:30pm Temperature: <4C F i aer. Present Lab No.: J0501449 Date Analyzed Test Name Result MCL Method 2/25/2005 16:00 2/25/2005 Total Coliform Absent Absent SMWW 9222B Chlorine Free Residual <0.1 mg /L N/A SMWW 4500CIG At the time of analvsis the sample was acceptable for total coliform N/A = Not Applicable S.U.= Standard Unit MCL- Max. Contaminant Level ug /L- micrograms per Liter mg /L- milligrams per Liter ND- None Detected NTU- Nephelometric Turbidity Unit TON- Threshold Odor Number Signature: Michael Lapman President Reviewed by: Sharon Houlahan, Director State #: PH -0218 ELAP #: 11715 CONNECTICUT, NEW YORK AND NELAC CERTIFIED Toll Free 866 -JMS -5097 I Corporate Fax 203 - 798 -2408 1 Lab Fax 203 - 798 -2107 1 www.jmsenvironmental.com IPgTI{'NAM COUNTY IlDIEiPAR'>1'IViIIENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Locagi6lm Street Address: 480 Farm to Market Road Town/Village: Patterson Tax Grid # Map 35. Block 3 Lot(s) 1 Well Owner: Name: Address: Joy & Andrew Hinton, 480 Farm to Market Rd, Brewster, NY 10509 Use of Well: I- primary 2-secondary X Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby )[Drilling ]Equipment X Rotary Cable percussion X Compressed air percussion Other (specify) Well Type Screened -- -Open end casing X Open hole in bedrock _ Other Casing Details Total length 32 ft. Length below grade 31 ft. Diameter 6 in. Weight per foot alb /ft. Materials: X Steel Plastic _ Other Joints: _ Welded X Threaded _ Other Seal: X Cement grout _ Bentonite Other Drive shoe: X Yes _ No Liner _ Yes X No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? !, First _ Yes No Hours Second Well Yield Test _ Bailed X Pumped X Compressed Air Hours 6 Yield 12 gpm Depth Data Measure from land surface- static (specify ft) 30' During yield test(ft) 160' Depth of completed well in feet 225' Well Log If more detailed information descriptions or Sigve:analyses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) (Formation )[Description ft. ft. Land Surface 0 Hitrock immediately ly 0 .32 Drilling in rock, set casing, routed .;32 ...2.25::.. D=ri.11ir g n_. -f-ack _ rariit.e - If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type sub Capacity 5hpm Depth 1801 Model 5GS05412 Voltage 230 HP 1/2 Tank Type WX255 Yglume8l gal s Date Well Completed 10/16/04 Putnam County Certification No. 004 Date of Report 3/28/05 Well r nature 1 p NOTE: Exact location of well with distances to at least two permanent landtrtarxs to be provided on a separate sneevpian. Well Driller's N . F, Beal �Vfonsjnc. Address: 4 Putnamhve. , Brewster, NY 10509 Signature: Date: 3/28/05 hit J. Beal White copy: HD File; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy- Well driller Form WC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH .. DIVISION OF ENVIRONMENTAEJ:NEALT -H SERVICES WELL ABANDONMENT REPORT I, undersigned, hereby certify that the abandoment of the above - referenced water well has been accomplished and completed in accordance with the methods described in Permit # W-41-0 to abandon said water well. Date: 9S - 1b) - OG Signature: Print Name: `- '_ON4'e19 (:�-16el-lc IV Address: Form WAR -97 PCHD Well Abandonment Permit # - - D please print or type Welt Street Address: TownNillage Tax Grid # Map �JSs Block Lot Name: Address: ifi= xll.i:t. •:• :i :_u. ?r; ,i�6;xFrl L" "lff •I NI� 4 %0 •:p"''1` �Y !x! 11 , rlf�UO�j W f '•'-i-!':!' "f /`�DI ✓fl_ 1 • `^' 1 °�V �d ::; •, - "" s;';. 1;..:.:i:;, Vin; + X Drilled Driven Dug Gravel Other lb of jeu: ;<:,; i.:4.:.,:. i Well Depth ft Static Water Level ft Date Measured ( °::_. ... -:•� ;k: : ,¢:.;pia:: „i. '.:. ' ''1..; ;gin.,;: =,•;; NEW wrEI.L I MI:6( 1V tD - S'o L,6 FE- 610- C� 0 Deg, rripfto�plOf.. ,J� �II�f� { ryf �y�'+�M `�(� ,.(� (� I^�,y �.�(' / �` �'N�1 r F l l ViD -"1 6!l"tIA- P Y 1 "�°,••y "� M•PM' lam, � i C �Y 6P V' I b u W `1 (Z ��''! �`lA I, undersigned, hereby certify that the abandoment of the above - referenced water well has been accomplished and completed in accordance with the methods described in Permit # W-41-0 to abandon said water well. Date: 9S - 1b) - OG Signature: Print Name: `- '_ON4'e19 (:�-16el-lc IV Address: Form WAR -97 FEE-21-2006 0:: 13 Ft 9 HARRY W NICHOLS 914 279 4567 P.01 PU NAM COUNTY DEPARTMENT OF HEALTH DMSIiON OF EN- MONMEN'TAL HLAL`H SERMES For: Full Date: 02- 0 1,. ~ ® ( Trenches X, PCHD Construction Permit # W ,41 04 f �' "! ►b -0�' �-~9 ��' Located; -"® FAON TO " �� (T) (v) Owner /Applicant Name: J 1 4� R1 *24 ® TM Block , Lot Formerly: Subdivision Name: Subdivision Lot # Is system fill completed? N K Is system complete? ' Yoh Is systein constructed as per plans? Is well drilled? Is well located.as per plaits? YES Are erosion control measures in place? e, Date: 4 ` It - b6 Date: OZ r V - 06 Date_ Qq,. "1'06 1 certify that the system(s), as listed, at the above premises has been constructed acid I have inspected and .verified their completion in accordance with the is PLM, Construction hermit and approved plans and the Standards, Rules and Regulati ounty Department of Health. Date _ �? `1- �'1� ' ti! Certified by: Address- X RA rVu14 Comments. Cr 1 Roa . 90, �(�K" \r' ��u gT1 SI�s It \)0%, y4 At UM FOR. d ADAM CrENF- ❑. . . (NAME) FEB -21 -2005 "UF 1.4:11 TEL:845- 278 -7921 NAME:PUTNAM COUNTY DEPARTMENT OF P. 1 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health Hang Nichols, P.E. Patterson Park, Ste 106 2050 Route 22 Brewster, NY 10509 Dear Mr. Nichols: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 March 1, 2006 Re: Field Inspection — Hinton Farm to Market Road (T) Patterson, TM # 35. -3 -1 ROBERT J. BONDI County Executive ROBERT MORRIS, .PE Director of Environmental Health The above referenced separate sewage treatment system can be backfilled. The following comments must be corrected in the field 1. Additional ROB fill needs to be installed in the expansion areas below and to the side of the new existing system. 2. The cast iron connection from house to septic tank needs to be inspected by this Dept. upon completion. If you have any further questions, please contact me at (845) 278 -6130 ext. 2261. GDR:ky Sincerely, -D I vz�. Gene D: Reed SR. Environmental Health Engineering Aide Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention /Preschool(845)278 -6014 Fax(845)278 -6648 a LORETTA MOLINARI Public Health Director ]DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Environmental Health (845)278-6130 Fax(845)278-7921 Nursing services (845)278-6558 WIC (845)278-6678 Fax(845)278-6085 Early Intervention/Preschool (845)278-6014 Fax(845)279-6648 Hinton 480 Farm to Market Rd. Patterson, NY 12563 Dear Mr. & Mrs. Hinton: May 24, 2004 ROBERT J. BONDI County Executive Re: Addition - Hinton, 480 Farm to Market Rd. No Increases in Number of Bedrooms (T) Patterson, TM #35. -3 -1 I have received and reviewed the plans for the proposed addition to the above - mentioned residence. The proposal for the addition has been approved as per plans bearing the approval stamp from this Department dated May 21, 2004. The addition is approved with the following conditions: 1. The total number of bedrooms must remain at four without prior approval by this Department. 2. The new septic system must be constructed as shown on approved plans dated May 21, 2004 drawn by Harry Nichols, P.E. 3. All plumbing fixtures must be updated with water saving devices, i.e., new low flush toilets, restrictors for shower heads and faucets, etc. Any other permits or variances required are the responsibility of the applicant and the jurisdiction of the Town of Patterson. If you have any questions, please contact me at your convenience. ML:lm cc:BI (T) Patterson Sincerely, 1� Michael Luke Public Health Sanitarian PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES . CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # FOPS -% A ®91- j 0 r,i , %00 . -p Located at 49 rA 0 M���l- � r * Town or Village ?A -rf < Subdivision name — Subd. Lot # Date Subdivision Approved f Owner /Applicant Name Mailing Address AU F". TO mf�R-' Amount of Fee Enclosed Building Type Lot Area No. of 1 Tax Map Block ':� Lot Renewal Revision Date of Previous Approval A kn N CA� o Zip 3edrooms 4 Design Flow GPD U0 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of 1�- 5 Q gallon septic tank and (bl LP Other Requirements: To be constructed by Address Water Suggly: Public.Supply From or: Private Supply Drilled byi� W J Address Address I represent that I am'wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment s, sY tem described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: Address R.A. Date 001 W- License # APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Approved for d' charge of domestic sanitary sewage only. By: Title: S Date: 2 f o White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUT NAM (COUNTY DEPARTMENT OIF HEALTH 14 _ J 3 SO o Y IIDII�SI� ®1 ®II' IEI �R ®I EIVIrAIL IH[IEAIL7TPT (!aI ID10ES APPLICATION TO CONSTRUCT A WATER WELL X-lei-ey pYease piint or type PCHD Perffir # Well Location: Street Address: Town/Village Tax Grid # 10 M ": PFM600 Map T5, Block /� Lot(s) WellOwneir: Name: Address: 4o Wm Z Mj-�aQ ,. P:A119 0 �1' jW Use of Well: Residential Public Supply Air /Cond/Heat Pump Irrigation 1- pirAmai °y Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought `5+- gpm # People Served .4 Est. of Daily Usage q W gal. Reason folr Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed ]reason ffo>r Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No _ Is well located in a realty subdivision? ...................................... ............................... Yes No _ Name of subdivision -° Lot No. -- Water Well Contractor: Address: Is Public Water Supply available to site? .................................. ............................... Yes No Name of Public Water Supply: -- Town/Village ° Distance to property from nearest water main: °- Proposed well location & sources of contaminatiptl to be provided on separat hee plan. Date: �0� Applicant Signature:.t I� PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED * FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam County. -a p,Grc Date of Issue �� 1 `� Permit Issuing Official: Date of Expiration Title: PAS Permit is Non- Transfe>r>rable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 1."...s PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO ABANDON A WATER WELL please print or type PCHD PERMIT # Well Location: Street Address: TownNillage Tax Grid # �- j1jjD ' TO M4Uf P0 , PATrWO 0 Map Block `) Lot(s) I Well Owner: Name:. J ,449KY �- Jo S iii fr -tiot� Address: 1410 FAQ 10 M46 (LO�Q Well Type: Drilled Driven Dug Gravel Other Depth Data: Well Depth ft Static Water Level ft Date Measured Use of Well: Residential Public Supply Air /Cond/Heat Pump Abandoned 1- primary Business Farm Test/Observation Other (specify) 2- secondary Industrial Institutional Standby Water Well Name: n Address: Contractor: F7� Reason For Abandonment: Description of Work To Be Performed: fju Date: 4Fd 1�D Applicant Signature: PERMIT This permit, to abandon one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code, Subpart 572 of Part 5 of the New York State Sanitary Code and/or Part 75 of 10 NYCRR and provided that: Within 30 days of the completion of the abandonment of the water well, the applicant shall submit to the Department a certified statement that the information delineated on the application for this permit has been completed. J s 17—Z '2— T Date of Issue Permit Issuing Official 00lT, Title White copy: HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WA -97 GC, BRUCE 'R. FOLEY'• .P..S .___.Acting Public Heatth- -ovi-: � DEPARTMENT--OF HEALTH Division Of Environmental Health Services , • -- -- - `4' Genzva ' Road; Brew j ster, New York 10509 � , / - U (914) 278 -6130 PRO?OSEO ADDITION APPLICATION _. (R.SIDENTIAL STP,�c�T: MoD o TOtirV IX M0 r. N, M, �: MAR r t 1µ PHONE , $ PCHD PER4IT MAILING ADME -SS _140 P4`` fi0 K 1 Description of-Addition ' . :, ... ... �.,. w...... Numberof existing b_edroaas Proposed number o.t..bedrooms - from;;-Qi eti irate o f Occupancy or Certification fro,-,FBuiIding Inspector A.ny addition which is considered a bedroom requires formal approval -o.f-. plais. . (Construction Parnit)' prepared•by• "a Professional Engineer or Registered Architect in accordance with applicable sections of the Putnam County Sanitary Code. Please submit this fore and the following to PUTM4 COUNTY HEALTH DEPARTMEYi•, 4 GEN VA ROAD, &REdSTER, W 10509, Phone 278 -6130 with the following information. _ .i,.Certified Check for $100:00: 2. Sketch of existing floor plan (all -living area including b _sement, if any) Non - professional drawing is acceptable. 3. Sketch of, proposed floor plan. Nonprofessional dr&ding is acceptable, 4. Copy of survey showing viel1 and - septic location; to the best_gf your . knowledge. -Ynclude'date of installation if known. Inc•lud `all` e'llt -and septic systens.within 200 feet of property line. Any questions plea- s-e-contact this office. 5. Copy.-of._Certificate.of Occupancy fro�m•Tarrn or Certjf-icati•on from- ••8u.i1ding Departriiarit of legal bedroom count of dwelling. OFFICE USE Corments and/or conditions ' .'O'Rpr 26 04 08:44a TOWN OF PRTTERSO 845-878-2019 P.1 APR-27-2004 e4:56 PM HARRY W NrCHOLS 914 279 4567 P.e2 BRUCE A. FOLEY. ka, Acting Mlic.Hislth Dirselof DEPARTMENT OF HEALTH Division,0f Environmental Health Servlc s 4 Cene4 Road, Brewster,. New York 10P09 (914) 278-6130 Putnam ' C6unty Dept. of Health 4 0eneva Road Brewster. NY 10509 Re. Residence Tax Map Wei) - Town— Gentlemen; According to records maintained by the Town, the above noted dwelling IS P IS NOT'' -" in compliance with ToNN-n code and the total number of bedrooms on record This information has been obtained from: CERTIFICATE OF OCCUPANCY: ASSESSORS RECORD: OTHER Building Insfektor Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Telephone (845) 279 -4003 Fax (845) 279-4567, April 27, 2004 Mr. William Hedges Putnam County Health Department 1 Geneva Road Brewster, New York 10509 RE: Individual SSTS - Repair /Addition Andrew & Joy Hinton 480 Farm To Market Road Patterson, NY T.M. # 35. -3 -1 Dear Bill: Enclosed are the following: 1. Five (5) prints of Drawing SS -1, "Proposed SSTS ", dated 04/27/04. 2. Short EAR 3. "Application for Approval of Plans for a Wastewater Disposal System ", dated 04/27/04. 4. "Construction Permit for Sewage Disposal System ", dated 04/27/04. 5. "Application to Construct a Water Well ", dated 04/27/04. 6. ...._ "Application for Proposed Addition" and letter from Building Department, dated 04/27/04. - 7. "Application to Abandon a Water Well ", dated 04/27/04. 8. "Design Data Sheet ". 9. "Letter of Authorization ". 10. Two (2) copies of residence floor Plan(s), for bedroom count only. 11. Review Fee in the amount of $100.00. / If there are any questions concerning the enclosed, please call. Very truly yours, t Harry W. Nichols Jr., P.E. HWN:gav 03- 086.00 ' 1416.4 (9/95) —Text 12 PROJECT I.D. NUMBER 617.20 SEAR Appendix C .....:,.., - _....r,�..,.:w:_•.... _..,.. ,... -. ,.. ..h , , . , <, ,� .. , . .: Stata� Er,�!s,:nr*��A.tt�l- 0�7'sty� :+3oView,.. .._r , ... ,.,< ,,.. ... ......_ . SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT /SPONSOR ,J AMDR e J Zvi NIMTD0 2. PROJECT NAME A D p M w to 66T 3. PROJECT LOCATION: p Q t (^ M v ro r� Municipality j UT-0 County 1 TAI 4. PRECISE LOCATION (Street address and road I rsections, prominent landmarks, etc., or provide map) 5..IS PROPOSED ACTION: Pr�afr ❑ New 11 Expansion KModiflcation /alteration 6. DESCRIBE PROJECT BRIEFLY: ADD lY 04 Tt E'-0'y-)kA , 667 h •Pe6IDN,!� 7. AMOUNT OF LAND AFFECTED: 1.0 t Sal Initially acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR -OTHER EXISTING LAND USE RESTRICTIONS? ,Yes ❑ No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? tZResldential ❑ Industrial ❑ Commercial ❑ Agriculture ❑ Park/Forest/Open space ❑ Other Describe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? ❑ Yes RN If yes, list agency(s) and permlUapprovals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑Yes RN If yes, Ilst agency name and permit/approval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑Yes No. I CERTIFY THAT THE INFORMATION(f PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE t J " ` �"yC` 1#,L-I'" ' Applicant/sponsor name: Date: Signature: rr If the action is in the Coastal Area, and you are a. state agency, complete the . Coastal Assessment Form before proceeding with this assessment OVER 1 PART II— ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.4? If yes, coordinate the review process and use the FULL EAF. Yes ❑ No B. PvIi:L ACTivh nEt.cfVE vtiVriGiN'A'Tcu hcviEb''�r:3•Pn'OViuw•i-OR uNi.iSTEJ ACTlvrZ IN u IvYGiiR, PART 617.6. it NJ, a neyeiivd iieClat'niitri, may be superseded by another involved agency. ❑ Yes ❑ No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing. traffic patterns, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain briefly. C5. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly. C6. Long term, short term, cumulative, or other effects not identified in C1-05? Explain briefly. C7. Other impacts (including changes in use of either quantity or type of energy)? Explain briefly. D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CEA? ❑ Yes ❑ No E. IS THERE, OR is :THERE LIKELY TO BE, CONTROVERSY RELATF_f) TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yes ❑ No If Yes, explain briefly PART III — DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whether it is substantial, large, important or otherwise significant. Each effect should be assessed in connection with its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting rndi vials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If question D of Part II was checked yes, the determination and significance must evaluate the potential impact of the proposed action on the environmental characteristics of the CEA. ❑ Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration. ❑ Check this box if you have determined, based on the information and analysis above and any supporting documentation, that the proposed action WILL NOT result in any significant adverse environmental impacts AND provide on attachments as necessary, the reasons supporting this determination: Name of Lead Agency Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Office r in Lead Agency Signature of Preparer(If different from responsible officer) to -X U I iN AIVI l.:.0 WN 1 X I)EI'A.K 11YlEIN. I 1 J•.k 'A-1� A-U'- M- - - - • .. - _, VI DfiSOMOF ENViRONNIENTAL HEALTH SERVICES` 1 y' . APP%ICATI'ON FOR APPROVAL OF PLANS. FOR - -. A VYASTEWATER TREATMENT' SYSTEM _ _ -- _ ..........:.. -..._ _ 1. Name and address of applicant: : 1f 1_ is 2. Name of project: 6 "1 �A!'`PI 'POOMW 3. Location T N. pA 4. Design Professional: MW V. , OL''J'me 5.. Xddress: q.05'0 J1 _6_: Drainage:Basin E�4J1 ��%�! • J _ j _ 7. Type 9f Project:' Private%Residential Food Service Commercial �- Apartments : - Institutional Mobile H ©me- Park,. • _. Office Building Realty Subdivision __ . Other (specify) ` 8. Is this project subject.to State Environmental Quality Review (SEAR)' - TYPe-Status (check-one-) .............................. .... ........................... Type I • ..:Exempf' . t. Type II Urilisted 9. Is a Draft Environmental'Impact Statement (DEIS) required? ......................... 10. Has DEIS been completed'and found acceptable. by -Lead Agency? .........;.:,. : ;j�?A� 11.' -Na'me of Lead Agency ....._12:.Is this,project in an -area under the •control of local planning, zoning, or other officials, ordinances ...... .......:. .......................:.:.. 13..Tf so, have plans. Q been submitted- authorities? ........ ............................... . . 14. Has preliminary approval been- grarited by such authorities? � .Date"granted:~ tJ 15: "Type of Se wage. Treatment-System Discharge. :::.....:.......T surface water �groundw� ter 16. :If surface wafer discharge; what is the stream class. designation? .....:.:...:...... �'.; Y1 17. Waters index number ( surface)...... ........................ ............................... 1.8...Is project located near•a public water supply system? ............... [J� 19.• If yes, name -of grater supply � � -Distance to water: su 1 . 10'� PP Y� -20: fs.pfoject site near a public sewage collection or txeatment.systern? 2i`. Name of sewage:sys`tem �' Distal?ce:fo sewage sysfem� '4, — 22. Date test- ho1•es• observed � ��� . ��j 21. Name of Health Inspectdr Btw � - 24. Froj:ect designflog (galltons_per day) ........ .. ............................. ..... , ............ 25. Is State Pollutant Discharge Elimination :System. (SPDES)- Permt.required ?.: 26. Has SPDES Application been submitted to local DEC office? ............' NA Form PC -97 .�- -.x: .. •.... .... .: �..: .. fir. .: .. ,.' .... ..•_..a a..i .., .+ /r � • '•'.. •' - •.. ..-- :.. -.-. ._ _.. -._ _ -.. •.a.•....... -21: Ts any portion: of this pro�.ect •located "wj.thin a designated Town or State wetland? 28. Wetlands .ID. Numb. er ... ............................... ...........•....... ,....................... : :.... 29. ""-Is Wetlands Permit required? .....:.:......:..:....................................................... Has application been made to, Town or Local .DEC office? .. .` ...:.......................... - 30. Does project require a DEC Stream. Disturbance:-Permil? .............................. I�Q 3 1 . Is or was project site used for agricultural activity involving application of pesticides to .orchards or other crops, solid ox, hazardous waste disposal, landfilli— q,'sludge application-or industrial activity? ............................ Yes%No 32.* Is project located within 1,000 feet..of existing or abandoned landfill, ... hazard o�is.�xaste site, salt stockpile, landfill, sludge disposal site or any other potentially known source -of contamination . ............................... Yes/No DESCRIBE: - 33. Is there a local master plan on.file with the Town or Village? .......... ............... t �S 34.. Are community water and/or sewer facilities.planned to be.devel6ped.W,ith1n -: 15 years in oz adjacent to project site? ................ ................................................. � • 35. Are any sewage treatment areas in excess of 15 % slope? fro 36. T�x:Man IT� ?�hirrher ......::- ° ......_... : ::... ...:. :.. : ...:.......... :.... N _ap J Flock �.. Lot 37. Approved plans are to be returned to ,.... Applicant Design 'Professional .�O�E: All applications far review and approval of new SST S. to be located within the NYC Watershed shall he.serit io the Department,. and need not be sent in duplicate to the DEP', although the. project may require DE-P' '-"approval of thei"SS•TS' pFrior io final: approval'by the Department. Projects' withia..the watershed.•may also — require DEP ieview. and:approval. of other aspects of a project, such as stormwater..plans._or. the" creation'of impervious •surfaces, and the project applicant should obtain the appropriate forms.. for such. activities from DEP and submit those forms to DEP for,-.review and -approval. - If the application is signed by a person other than the applicant shown -in Item I :,the application must 'be accompanied by a Letter of Authorization (Form LA -97): Failure to comply with this :provision �v1® may, be grounds for. the rejection of any submission. I hereb , .a irm; under penalty ofperjury, that.. inform ati'M ro.vided.on ihis orm . is trc .Oda ff _ to the best of * my knowledge and belief. False statements made herein. are punishable 1 - --6:, a Class A misdemeanor. pursuant to Section 210.45 of -the Penal'L ,. SICMA•TURES -& - OFFICIAL TITLES: -41� .4 A,11, Mailing Address:- ........ ........ ....... � 1r' �I iv l✓S :1 tiV ' ( � UALTH PUTNAA-KC 40 .1 DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE '-SEWAGE -:TREATMENT SYSTEM Owner': 1AH P�gw -f- .. joy wHrW.. Address' Ai o FA?A ..V� 1 X56"1 Located at (Stre6t).4ULM _O-'6AW-7 ax Map B*10*'ck' L'O-1 (tndicate_nearest'cr(?ss §treet) Municipality Watershed OLAk Date of Prb-soakin SOIL..' PERCOLATION TEST DATA iresRiw go 7peam at same depm unit approximately equal percolation rates are obtained at each pp&olafi6h test hole. min f6r 1-30 min/inch, s 2 min for 31-60. min/inch) All-data to bi7 -submitted for review., 2.'. Depth measurements to be made from -top of hole. Form DD-97 i Z ;Pr jrOm' ...r V PP ..2 3 lot. L .2- 3- ?Ll"i. I iM __Uj I 4 2 3 .5 iresRiw go 7peam at same depm unit approximately equal percolation rates are obtained at each pp&olafi6h test hole. min f6r 1-30 min/inch, s 2 min for 31-60. min/inch) All-data to bi7 -submitted for review., 2.'. Depth measurements to be made from -top of hole. Form DD-97 i G.L. 0.5 1.01 1.51 2.0' 2.51 : I 3.0' 5 M AO� IN 3.5 4.0 4.51. 5.0 5.5. ---------- 6.0' 6.5 7.01 7.51 8.01 8.51 9.0 10.01 Indicate level at whichigroundwateirf-i's 'encountered Indicate level.atwhich. mottling is observed Indicate level to which water level rises after being encountered Deep hole observatio'n's"'rna'de by: JM- Date ILI —M Design Professional Name:-. Em t!kUpoU jvw, Address: �.O sO tiff Signaturc 2 Design Professional's Sial i e M T 2 :�: �s•xv,:> PU I EN AM COUNTY IjEPARTM NT OF .HEALTH DIVISION �OF.EhIVIRONMENTAL HEALTH -SERVICES.: : LETTER OF AUTHORIZATION Property ofMW J p jJM�ip� -) __ _ ;_- v .t . Located at �o �� i �F_ L-1 I. TN P "' Subdivision -of Subdivision Lot # . . Gentlemen: Tax Map #�' Block _Lot i Filed Map # Date Filed.. —� This letter is to authorize ��'�'� ��� 0%�7 V a duly licensed Professional Engineer 2- or Registered Architect to_pp y for the:req#ed wastewater treatment .and/or water supply permit(s) to serve the above- noted - property in :accordance: . with the standards, rules or regulations.as promulgated by the Public 14ealth Director cf.tlie ffi" ni County Health Department, and to sign all necessary- papers on my behalf in connection. th =this matter and to supervise the construction of said wastewater tretment and/or water supply syste in conformity with.the.pro isions..of Article 145 and/or. 147 of the Education. Lam,- .•'he.,Public•Healthi.,-. -.. --- ..,- Law, and "tiie Putnam County Sanitary Code. -C,ountersigii� P.E., R.A., # , Mailing Of NEW State Zip' 5� Telephone: Very truly Signed: (O n r e roperry) Mailing Address: Forui LA -97 P A State Telephone:. Forui LA -97 V SHEIBLITA AMLER, MD, IBS, FAAP Commissioner of Health LORETTA 1 OLINARI, RN, MSN Associate Commissioner of Health Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Dear Mr. Nichols: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 September 6, 2006 Re: Field Inspection- Hinton Farm to Market Road (T)Patterson, TM #35. -3 -1 A re- inspection at the above referenced lot has been completed. There are no further comments to be addressed. RO' BERT J. H®NDI County Executive ROBERT MORRIS, PE Director of Environmental Health If'you have -any further- questions, please contact me at-(845" 278 - 61-30; ext: 2261 Sincerely, GDR-lm Gene D. Reed Sr. Environmental Engineering Aide Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225- 5186::Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early InterventioniPreschool (845) 278 -6014 Fax (845) 278 -6648 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES - /OD -D APP, LICATION TO CONSTRUCT .A: WATER WELL,. Permit # please print or type PCHD Well Location: Street Address: Town/Village Tax Grid # /►,, i Map my 4 Block '/ Lot(s) I Well Owner: Name: mwbD }1�i Address: 4-%o `sb 0. PR %KSQ'' �1 Im Use of Well: Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought �� gpm # People Served Est. of Daily Usage 190 gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ......... ............................... ............................. Yes No Name of subdivision -- Lot No. -- Water Well Contractor: Address: Is Public Water Supply available to site? .................................: ............................... Yes No Y_ Name of Public Water Supply: Town/Village Distance to property from nearest water main: Proposed well location & sources of contaminatio to be provided on separat ee plan. Date;" �� _ .A" licant.Si at�.irA:.. A;A.. M PERAUT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well killing operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED_FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam County. Date of Issue ��z �. ° Permit Issuing Official: Date of Expiration Title: 104-5. Permit is Non - Transferrable White copy- HD file; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy -Well driller Fnrm WP.07 Pa I•, SEAL & SONS, INC. 6.1960 ARTESIAN .WELLS - PUMPING EQUIPMENT WATER CONDITIONING EQUIPMENT BREmm. w 10608 50-2* 768 OAYE ^ 218 FAY TO THE ORDER OF DO DOLLARS Ewol ooa,oaraa ' YOGI( �ma® +1®0619601F+ta02 1902352'® 1180078202378118 PUTNAM COUNTY DEPARTMENT OF HEALTH OF ENNIPIONITNUENTAL HEALTH SERVICES APPLICATION TO ABANDON A WATER WELL nleace nrint nrtvnr PCHD PERMIT # Well Location: Street Address: TownNillage �- Tax Grid # A"D T4 N . "i pA�Ta tJ Map' , Block *� Lot(s) Well Owner: Name: Oar► t Jo � t-�t �oc� Address: �a � ib (�.� � � t�l`� Well Type: X Drilled Driven Dug Gravel Other Depth Data: Well Depth ft Static Water Level ft jDateMeasured _j Use of Well: Residential Public Supply Air /Cond/Heat Pump Abandoned 1= primary Business Farm Test/Observation Other (specify) 2- secondary Industrial Institutional Standby Water Well Name: nn nn Address: �F7tJ Contractor: Reason For Abandonment: Description of Work To Be Performed: NEAT ctmEW Date: I Y \� Applicant Signature: PERMIT This permit, to abandon one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code, Subpart 5 72 of Part 5 of the New York State Sanitary Code and/or Part 75 of 10 NYCRR and provided that: Within 30 days of the completion of the abandonment of the water well, the applicant shall submit to the Department a certified statement that the information delineated on the application for this permit has been completed. n ° Date of Issue Permit Issuing Official Title White copy: HD file; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy -Well driller Form WA -97 Joy Hinton 7 480 FarmTo market Rd,Brewster t-4 5 02 Tax MA2 #35-3-1 N 76'34' 54• 11 78' 47' N 71' 24' 18' N 813' 26' 19' JPROJ). VNIE 1•t- 71' 39'07" \N EXIST WELL TO k33 -t'N 73' 06' 43' \N X34: - 06' 40" 4.: N 72 N 69'4 O"' ''� C rG] � I PC) U7-U Rc- ,>V N pk CPO, ,, a, m� \3 R 0 Is CA Sen r, �AQgGF 13 brx4c \ ` 80-DA \,NN 00 1*15 rr!N 4, Ail< A IN, 1p V4= Q SIbR as 82 .480 Pr lopvc. Putnam Valley Road Names Southeast Road Names Disclaimer: Page 1 of 1 n.:PRINTOUT-RT�E.— J-1 http:// imsserver .putnamcountyny.comIFreeance / Client ILandRecordslprintFrame.htrnl 7/22/200' Town Lines D Parcels - Old Parcel Lines f/ Streams Lakes and Ponds Wetlands Carmel Road Names Kent Road Names Patterson Road Names Philipstown Road Names Putnam Valley Road Names Southeast Road Names Disclaimer: Page 1 of 1 n.:PRINTOUT-RT�E.— J-1 http:// imsserver .putnamcountyny.comIFreeance / Client ILandRecordslprintFrame.htrnl 7/22/200' (in feet) B 33 - 37 42. 4-7 53 so 63 10 64 54 50 _ 4-I 86 8l 90 93 96 100 EXISTfNG ASANDO46P WELD. 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